Watchful waiting: role of disease progression on uncertainty and depressive symptoms in patients with chronic hepatitis C.

BACKGROUND AND AIMS: New therapies for HCV are rapidly emerging and providers are advising select patients to defer treatment and elect 'watchful waiting'. During the watchful waiting period, patients have been shown to have high rates of illness uncertainty and depression. We sought to answer the question of whether reassuring histological data (showing minimal fibrosis or no fibrosis progression over time) is associated with less illness uncertainty and depressive symptoms. METHODS: This was a single-centre outpatient prospective cohort study to determine whether stage of fibrosis, fibrosis progression and reasons for treatment deferral were related to illness uncertainty and depressive symptoms in patients following watchful waiting. RESULTS: Illness uncertainty was significantly related to depressive symptoms (r = 0.49, P < 0.01). More than half of the participants (54%) had moderate levels of uncertainty. About 40% of the participants were at risk for clinical depression (21.7% at mild to moderate risk and 18.5% at high risk). Treatment naïve subjects had lower mean scores on both the CES-D (depressive symptoms measure) and the MUIS-A (illness uncertainty measure) total score, MUIS-A Ambiguity subscale and MUIS-A Inconsistency subscale than subjects who failed treatment or were interferon intolerant or ineligible. Surprisingly, liver fibrosis stage and progression were not significantly associated with overall illness uncertainty or depressive symptoms. CONCLUSION: Patients with chronic hepatitis C on watchful waiting are at high risk for significant illness uncertainty and depressive symptoms. Reassuring histological data does not seem to correlate with less uncertainty or depressive symptoms.

Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting.

OBJECTIVE: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting. METHODS: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group. RESULTS: Baseline characteristics were similar. The number of grafts performed per patient (mean +/- SD 3.39 +/- 1.04 for off-pump coronary artery bypass grafting, 3.40 +/- 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 +/- 0.18 for off-pump coronary artery bypass grafting, 1.01 +/- 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 +/- 6.5 for off-pump coronary artery bypass grafting, 6.1 +/- 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days. CONCLUSIONS: When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Fracture healing in tibia fractures with an associated vascular injury.

BACKGROUND: Tibial fractures with an associated vascular injury are a challenging management problem for the orthopedic and vascular surgeon. The effect of a concomitant vascular injury on fracture healing has not been specifically delineated previously. METHODS: We performed a retrospective review of 29 fractures of the tibial shaft with an associated vascular injury in 28 patients. RESULTS: Overall there were 44 vessels injured (38 arterial and six venous). A total of six patients had an amputation performed; patients requiring amputation were significantly older than those without amputation. Fractures with an associated injury to the posterior tibial artery had a significantly higher nonunion rate and a greater number of weeks to union than fractures without this vascular injury. CONCLUSION: Outcomes of tibial fractures with an associated vascular injury are poorest in older patients (who are at increased risk of amputation) and those with an injury to the posterior tibial artery (who are at increased risk of delayed union and nonunion).

Reproduction and teratology study of 1,3-butanediol in rats.

The effect of 1,3-butanediol on reproductive performance as well as its teratogenic, dominant lethal and cytogenetic effects were studied in five generations of Wistar rats. Animals of both sexes were fed either control diet or diet supplemented with 1,3-butanediol at dose levels of 5, 10 or 24% of the diet by weight. Reproduction and lactation parameters were comparative to controls for four of five generations of dams and pups. In contrast, the pregnancy rate of F1A rats decreased during five successive mating cycles; no pups were obtained in the high-dose level group of the fifth series of litters (F2E generation). Excluding this group, the viability of F2 generation pups revealed no significant differences between litters or between control and test groups. No definitive dose-related teratological findings were found in either soft or skeletal tissue examinations of F3B generation rats. However, incomplete ossification of sternebrae occurred frequently in mid- and high-dose fetuses, whereas missing sternebrae were noted especially in high-level fetuses. Both skeletal tissue findings suggest slight delayed fetal growth. For the dominant lethal assay of the F1B generation, the mutagenic index (percentage resorptions per implant sites) revealed no dose-related trend. In the three-generation cytogenetic study, no 1,3-butanediol related chromosomal aberrations were noted.

Suspected infectious necrotic hepatitis (black disease) in Oregon cattle.

Suspected infectious necrotic hepatitis (black disease) in a herd of 436 cattle in Douglas County, Oregon, resulted in 79 deaths during a 2-week period. Although Clostridium novyi could not be isolated from hepatic lesions, the clinical course of the disease, gross and histopathologic findings, and fluorescent antibody identification of C novyi in various tissues were suggestive of the disease. The epizootic was preceded by a long drought, during which grazing conditions were sparse. A few days before the 1st dead animal was found, the drought was relieved by about 10 cm (4 in) of rainfall, resulting in the growth of young succulent grass. The cattle, attempting to eat this new grass lying close to the ground, consumed large quantities of soil. It was speculated that the soil contained C novyi and that the proliferation of these ingested organisms in necrotic tissue cuased by Fasciola hepatica resulted in fatal toxemia.